Int. J. Pharm. Sci. Rev. Res., 23(1), Nov – Dec 2013; nᵒ 03, 13-16
ISSN 0976 – 044X
Research Article
A study of pleural fluid Adenosine Deaminase activity in tubercular and
non-tubercular pleural effusion
1
2
3
4
3
Priyadarshini K.S , Aliya nussrath , Devaki.R.N , B.K.Manjunatha Goud , Deepa. K
1
Department of Biochemistry, Raja Rajeshwari Medical College, Bangalore, India.
2
Department of Biochemistry, AIMS Bellur, India.
3
Department of Biochemistry, JSS Medical College, JSS University, Mysore, India.
4
Department of Biochemistry, Ras Al Khaimah Medical and Health Sciences University, Ras Al Khaimah, U.A.E.
*Corresponding author’s E-mail: devakirangaswamy@yahoo.com
Accepted on: 22-06-2013; Finalized on: 31-10-2013.
ABSTRACT
One of the most common complication of primary tuberculosis in India is exudative pleural effusion. Adenosine deaminase (ADA) is
an enzyme produced by activated T- lymphocytes in response to the mycobacteria tuberculosis infection. ADA levels in pleural fluid
will be comparatively higher than the serum levels suggesting the local synthesis of ADA by activated T-lymphocytes. Thus the
estimation of ADA in tubercular pleural fluid helps in the diagnosis of tubercular pleural effusion. The objective of this study was to
find out the role of ADA levels to differentiate tuberculous and non-tuberculous exudative pleural effusions of other aetiologies.
Thestudy comprises of 50 randomly selected cases, having of pleural effusion of different aetiologies and are admitted in the
medical ward at a tertiary care hospital. The study found that pleural fluid ADA levels were significantly higher (p<0.001) in
tuberculous exudative pleural effusions when compared with non-tuberculous exudative pleural effusions. Hence, determination of
ADA level in exudative pleural effusions is cost effective, rapid and simple procedure which should be considered for routine
investigation of patients with pleural effusion, especially in a country like India where tuberculosis still overwhelmingly out numbers,
the other causes of lymphocytic pleural effusion.
Keywords: Adenosine Deaminase, Exudative pleural effusion, Mycobacterium Tuberculosis.
INTRODUCTION
T
uberculosis (TB) is a serious global health problem,
as one-third of the world population is estimated to
be infected with Mycobacterium tuberculosis and
8.7 million new active cases seen annually.1 Tuberculosis
is second only to HIV/AIDS as the greatest killer
worldwide due to a single infectious agent and 1.4 million
died from TB annually.
In India due to low socioeconomic status, unawareness
about hygienic practices has led to increased cases of TB.
Pleural effusion is one of the most common causes of
exudative pleural effusion and results as a complication of
primary pulmonary tuberculosis which causes the rupture
of tubercular cavity into the pleural space.
Apart from other causes of pleural effusion TB stands high
in rate, although tubercular pleural effusion can resolve
spontaneously but up to 65% untreated tubercular
pleural effusion can develop active tuberculosis.2
So rapid and accurate diagnosis and prompt treatment is
necessary for tubercular pleural effusion.
To differentiate tubercular pleural effusion from nontubercular pleural effusions like malignancy, pneumonic
effusions, transudative
effusions etc, requires
confirmatory test. A definite diagnosis of tuberculous
pleural effusion can be made only when tuberculosis
bacillus is found either in the smear or culture of pleural
fluid material, pleural tissue or granuloma in the parietal
pleura in pleural biopsy specimen.3 Tubercular bacilli are
rarely positive in pleural fluid smear or culture. Culture
reports take 6 to 8 week time and are not widely available
in all health care centres.
However, pleural biopsy is an invasive procedure and is
associated with life threatening complications. There is
need for rapid, safe simple, sensitive and non invasive
laboratory test for the diagnosis of tubercular pleural
effusion.
Adenosine deaminase is an enzyme of purine catabolism,
it catalysis the conversion of Adenosine to Inosine. Its
principles biologic activity is detected in T-lymphocytes
and its level remains high in disorders where cellular
immunity is stimulated and tuberculosis is one such
disease. ADA level in tubercular plural effusion is
markedly increased compared to non-tubercular
effusions. Hence this study was undertaken to determine
ADA activity in pleural fluid and its role in differentiating
the cause of pleural effusion.
MATERIALS AND METHODS
The study group comprised of 50 randomly selected cases
of exudative pleural effusion with different aetiologies.
Both male and female patients in the age group of 22 to
65 years admitted in the medical ward from a tertiary
care Hospital, Adichunchanagiri Institute of Medical
Sciences, Bellur.
Inclusion criteria
1.
Clinically diagnosed cases of exudative pleural
effusion of tubercular and other different aetiologies
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Int. J. Pharm. Sci. Rev. Res., 23(1), Nov – Dec 2013; nᵒ 03, 13-16
(Based on the concentration of protein in pleural
fluid >3gm/dl and cell count >1000cells/µL).
2.
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differentiate tubercular from non tubercular pleural
effusion.
Cases with transudate pleural effusion
Exclusion criteria
History of typhoid fever, acute viral hepatitis and cirrhosis
of liver were excluded.
The cases were confirmed and grouped based on clinical
and X-ray results. With the informed consent of the
patient, the site for pleural fluid aspiration was selected
either in mid axillary line or posterior axillary line in the
6th, 7th or 8th intercostal space. Under aseptic precautions
skin, subcutaneous tissue, intercostal muscles and
parietal pleura are infiltrated with 5 to 10 ml of 2%
lignocaine.
Thoracocentesis was performed using 18 G needle
attached to a 20 or 50 cc syringe at the proposed site and
fluid is aspirated and collected into sterilized bottle.
The pleural fluid were analysed for protein, sugar, lactate
dehydrogenase (LDH) and ADA levels.
Estimation of pleural fluid glucose level is done by glucose
oxidase method, total protein by Biuret method, LDH by
kinetic method in ERBA-CHEM-5 semi automated
analyzer.
Adenosine deaminase was estimated by Giusti and
Galanti colorimetric method. The ammonia which is
produced during the reaction was assayed by modified
Berthelot reaction.
Statistical analysis
The results were subjected to analysis using SPSS
software and the results were expressed as mean ±SD.
RESULTS
In the present study, we analyzed the ADA activity in 50
cases of pleural effusion with different causes, out of
which 30 cases were of tubercular aetiology, 5 cases were
malignant, 10 cases of para pneumonic and 5 cases were
of transudative effusion as shown in the Table 1 and chart
1.
Table 1: Distribution of different types of pleural effusion
with their aetiologies
Causes of pleural effusion
No. of cases
Percentage (%)
Tubercular
30
60
Malignant
05
10
Para pneumonic
10
20
Transudative
05
10
The study result showed the ADA activity in tubercular
effusion was significantly higher (88.53 ± 17.7, p<0.001)
compare to non – tubercular pleural effusion like
malignant (34.6 ± 8.5), parapneumonic effusions (26.4 ±
9.3) and transudative effusion (13.8 ± 3.2). This indicates
that, estimation of ADA is a very good parameter to
Chart 1: Distribution of different types of pleural effusion
DISCUSSION
In our study, all cases of exudative pleural effusion
(tuberculosis, malignant and para pneumonic effusion)
showed higher level of protein (>3.5gm/dl) and LDH
(>200mg/dl) than the transudative pleural effusion cases
except the glucose level. Which is in accordance with the
Light’s criteria of classifying transudative and exudative
effusions.
The activity of ADA was found to be more in tubercular
pleural effusion than in cases of non-tubercular pleural
effusions and found to be statistically significant
(p<0.001).
Piras M.A., et al (1978) were one of the earlier workers
who studied ADA activity in pleural effusion of different
aetiology and concluded that the tubercular pleural fluid
ADA activity was significantly higher when compared to
different non tubercular cases.4
S.K. Sharma., et al., 2001 studied the ADA activity in
pleural effusions of tubercular and non tubercular
aetiology such as malignancy, para pneumonic,
empyema, transudative, immunological disorders (like
SLE, rheumatoid arthritis sarcoidosis etc.) and found that,
ADA activity in tubercular pleural effusion was high when
compared to non – tubercular pleural effusion.5 Our
present study findings are consistent with the above
workers.
In tuberculosis there are increased numbers of Tlymphocytes and macrophages in pleural fluid which may
be associated with highly elevated ADA activity in such
patients. The ADA activity is greater in lymphocytes and is
related to differentiation of lymphocytes.
Tom Petterson., et al, in 1984, studied ADA activity both
in serum and pleural fluid in patient’s pleural effusions of
different aetiology. They found higher levels of ADA in
tubercular pleural effusion and they also found higher
ADA activity in pleural fluid than in serum indicating a
local synthesis of ADA by T- lymphocytes.6
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Int. J. Pharm. Sci. Rev. Res., 23(1), Nov – Dec 2013; nᵒ 03, 13-16
R. P. Sing, et al (1986), showed that, pleural fluid ADA
activity was significantly higher in tubercular effusion,
when compared to malignant and transudative effusions.7
Gilhothra R., et al., (1989), compared tubercular pleural
fluid ADA with non – tubercular pleural fluid ADA and
concluded that, higher values of ADA is strongly
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suggestive of tubercular aetiology. However, in this work,
4 out of 26 cases of malignant effusions also showed
higher ADA levels, but they concluded that, pleural fluid
ADA levels of less than 40 units/L excludes tubercular
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aetiology.
Table 2: Distribution of pleural fluid glucose and protein in various types of pleural effusion
Type of pleural effusion
Pleural fluid glucose
range mg/dl
Pleural fluid glucose mean ±
SD
Pleural fluid Protein
range gms/dl
Pleural fluid protein
mean
Tubercular
50-100
67.3±14.12
3.5-6.4
4.63±0.6
Malignant
40-82
78.4±9.16
4.0-5.1
4.38±0.5
Para pneumonic
48-62
54.8±5.05
3.8-5.0
4.49±0.6
Transudative
92-138
107±16.27
1.3-2.5
1.98±0.4
Table 3: Distribution of LDH and ADA in different types of pleural effusion
Type of pleural effusion
Pleural fluid LDH U/L
Mean ± SD
Pleural fluid ADA U/L
Mean ± SD
Tubercular
220-1316
518.36±207
50-117
88.53±17.7
Malignant
620-920
778.4±116.7
20-45
34.6±8.50
Para pneumonic
382-560
460.2±53.5
13-47
26.4±9.3
Transudative
90-160
120±29
10-18
13.8±3.2
Graph 1: ADA activity in pleural fluid of different types of pleural effusions
Table 2, 3 and graph 1 showing the values of pleural fluid protein, LDH and ADA levels in various conditions.
ADA is present in most cells of the organism and is
associated with the proliferation and differentiation of
lymphocytes, especially T lymphocytes. The concentration
of ADA in these lymphocytes is inversely proportional to
5
their degrees of differentiation. ADA has gained
increasing attention as a diagnostic tool, especially in
9-13
countries where the prevalence of TB is high.
In our study the ADA activity in malignant effusions was
less compared to tubercular pleural effusions.
CONCLUSION
In the present study an attempt has been made to
estimate the pleural fluid ADA activity in pleural effusion
of different aetiology.
Most current laboratory tests like pleural tissue culture
and histopathology are slow, invasive, comparatively less
sensitive and their results depends on the availability of
expert opinion. From the present study it is evident that,
measurement of ADA in pleural fluid is a rapid, safe
simple, sensitive and non invasive laboratory test for the
diagnosis of tubercular pleural effusion.
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Int. J. Pharm. Sci. Rev. Res., 23(1), Nov – Dec 2013; nᵒ 03, 13-16
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ADA estimation being a simple colorimetric method, is
imminently suitable for the rapid diagnosis of tubercular
effusion in field setting.
8.
Gilhothra R, Schgal S, jindal SK, “Pleural biopsy and
adenosine deaminase anzyme activity in effusions of
different etiology”, Lung India, VII (3), 1989, 122-124.
REFERENCES
9.
Ocana I, Martinez-Vazquez JM, Segura RM, Fernandez-DeSevilla T, Capdevila JA, Adenosine deaminase in pleural
fluids:Test for diagnosis of tuberculous pleural effusion,
Chest, 84, 1983, 51-53.
1.
World Health Organization, Tuberculosis Fact sheet N°104
Reviewed February, 2013.
2.
Roper WH, Waring JJ, Primary serofibrinous pleural
effusionin military personnel, AM Rev Respir Dis, 71, 1995,
616–634.
3.
Amitabha Basu, Indranil Chakrabarti, Nilanjana Ghosh,
Subrata Chakraborty, A clinicopathological study of
tuberculous pleural effusion in a tertiary care hospital, 5, 3,
2012, 168-172.
4.
Piras MA, Gakis C, Adenosine deaminase activity in pleural
effusion, An aid to differential diagnosis, BMJ, 2, 1978,
1751- 1752.
5.
Sharma SK, Mohan A, “Adenosine deaminase in the
diagnosis of tubercular pleural”, India J. Chest Dis Allied Sci,
38, 1996, 69-71.
6.
Tom petterson, KaasinaOjala, Theodor H. Deber,
“Adenosine deaminase in the diagnosis of pleural effusion”,
Acta Med. Scand, 215, 1984, 299-304.
7.
Singh RP, Narayan RK, KAtiyar SK, et al., “Adenosine
deaminase activity in pleural effusion”, JAP1, 34(6), 1986,
427.
10. Valdes L, San Jose E, Alvarez D, Sarandeses A, Pose A,
Chomon B, Alavarez-Dobano JM, Salgueiro M, Rodrigez
Suarez JR, Diagnosis of tuberculous pleurisy using the
biologic parameters adenosine deaminase, lysozyme, and
interferon gamma, Chest, 103, 1993, 458-465.
11. Burgess LJ, Maritz FJ, Le Roux I, Taljaard JJ, Combined use
of
pleural
adenosine
deaminase
with
lymphocyte/neutrophil ratio:increased specificity for the
diagnosis of tuberculous pleuritis, Chest, 109, 1996, 414419.
12. Riantawan P, Chaowalit P, Wongsangiem M,
Rojanaraweewong P, Diagnostic value of pleural fluid
adenosine deaminase in tuberculous pleuritis with
reference to HIV co infection and a Bayesian analysis,
Chest, 116, 1999, 97-103.
13. Villegas MV, Labrada LA, Saravia NG, Evaluation of polymerase chain reaction, adenosine deaminase, and
interferon-gamma in pleural fluid for the differential
diagnosis of pleural tuberculosis, Chest, 118, 2000, 13551364.
Source of Support: Nil, Conflict of Interest: None.
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